Humanise and demedicalise Undetectable=Untransmittable in Thailand

Introduction

In February 2020, a post made by a Thai influencer offering to teach the public how to have safe bareback sex was shared on Facebook by a student nurse who used an angry caption.¹ The influencer is open on social media about living with HIV, his sex work, and use of stimulant drugs. He used Undetectable=Untransmittable (U=U) as a back-up theory for this particular post, which was made in January 2019. This incident sparked a large public outrage with hundreds of thousands of users on Facebook and Twitter condemning his condomless sex as irresponsible, a Buddhist’s sin, and a public threat. A few HIV doctors who spoke publicly in support of U=U received an extreme backlash, including death threats and threats from fellow doctors that their medical licenses should be removed. Several doctors criticised the science of PARTNER, PARTNER2, and Opposites Attract,^2–4 which demonstrated that people living with HIV (PLHIV) who achieve and maintain an undetectable viral load by taking and adhering to antiretroviral therapy as prescribed cannot sexually transmit the virus to others, as inapplicable to Thailand’s setting.

A call-for-action was subsequently made by the Institute of HIV Research and Innovation (IHRI) asking for these following actions.¹ Relevant stakeholders must expand truths and challenge misconceptions about U=U and ensure this science is put into practice. Doctors need to be formally educated about U=U and how to apply it in clinical practice. In Thailand, medical authorities such as the Ministry of Public Health (MOPH), Thai AIDS Society, and Thai Medical Council, as well as Thai Network of People Living with HIV (TNP+), must publicly endorse U=U. International HIV communities, researchers, clinicians, PLHIV, and policymakers should seriously strategise dissemination of this evidence-based U=U message to educate wider global communities. Other preventive methods must be made accessible in a non-judgmental way to people who made an informed decision to practice condomless sex, regardless of their HIV status. Several statements from the Prevention Access Campaign and Asia Pacific Coalition of Male Sexual Health, the International AIDS Society, Principle Investigators of studies that generated U=U science, the World Health Organization, UNAIDS, and Thailand MOPH were issued to support this call-for-action.^5–7

The momentum of U=U implementation in Thailand changed when U=U was endorsed in June 2022 by the National AIDS Committee as a key strategy for ending AIDS. This was a result of a yearlong effort carried out by its Subcommittee on AIDS Rights Protection and Promotion. The Foundation for AIDS Rights (FAR) and the Thailand MOPH’s Department of Disease Control acted as the Subcommittee’s civil society and government co-secretariats, respectively. U=U was proposed by the Subcommittee to the National AIDS Committee as a science, which needs an urgent translation into actions to address pervasive stigma faced daily by PLHIV in healthcare, workplace, and educational settings.

Exploring U=U values among PLHIV, their partners and healthcare providers

The Joint United Nations Programme on HIV/AIDS (UNAIDS) Focal Country Collaboration initiative on stigma and discrimination awarded a grant to the team co-led by IHRI, FAR, and TNP+ in June 2022 to implement a program titled ‘Using U=U to explore and address multi-level and intersectional HIV-related stigma and discrimination’. The program aimed to humanise and demedicalise U=U by exploring a ‘people-centred value’ of U=U given by various stakeholders and translate these values into efficient U=U communications beyond the healthcare setting. To humanise U=U is to inject compassion and empathy into the meaning of U=U to make it more pleasant and suitable for people. To demedicalise U=U is to shift from a disease-focused to a people-centred approach in communications through demystification, destigmatisation and decentralisation.⁸

During August–September 2022, in-depth interviews were conducted with 43 PLHIV and 17 partners of PLHIV in serodiscordant relationships representing people from various backgrounds, including those who were gender-diverse, migrants, sex workers, using drugs, and living in five different regions of Thailand. Focus group discussions were also held with 28 healthcare providers and 11 PLHIV peers in hospitals from these five regions. The interview and focus group discussion guides were developed together with Thai PLHIV and HIV healthcare providers. No ethics review approval was sought as this was considered part of a scoping review for the National U=U Training Curriculum development. Those who participated in the interview and focus group discussions were compensated 500 THB for their time and travel. Thematic analysis was used for data analysis.

Findings from in-depth interviews and focus group discussions

Among PLHIV, how U=U frees them up to ‘live a full life’ was valued highest. A great relief from sin, immorality, and irresponsibility was mentioned by all PLHIV after knowing about U=U. Both PLHIV and their partners foresaw that U=U communications would allow them to be able to love, to be loved, and to enjoy intimacy and sex with pleasure again. A majority of PLHIV and their partners stated that they should have been told about U=U decades ago (Table 1).

Healthcare providers and PLHIV peers, when asked about their thoughts on U=U, almost always refer the first value of U=U to ‘physical health’ and a long healthy life. The value of U=U in ensuring that PLHIV can also live a normal life usually comes after. U=U science is heard although without adequate opportunities for HCPs and PLHIV peers to have their concerns addressed or clarified. Many myths from the past were still used to guide counselling practice, (e.g. PLHIV can acquire new (drug-resistant) HIV strain from others, even with an undetectable viral load, if they did not use a condom). There were also common concerns around increasing sexually transmitted infections and unplanned pregnancies with condomless sex. Once remaining myths and concerns were clarified, healthcare providers felt unlocked; they felt much more confident in communicating U=U directly and correctly.

Strategies to humanise and demedicalise U=U

Power imbalance in a paternalistic provider–client relationship does not support client’s autonomy to make an informed health decision in a Thai healthcare setting. The hierarchical healthcare system in Thailand also portrays a doctor as a gatekeeper for any new innovations to be implemented. Together, these medicalised U=U acted as main barriers to the communication of the U=U theory.⁹ Healthcare providers in general are not sensitised and lacking skills in communicating about sexual life, sexual health and relationships with their clients. The people-centred values of the U=U theory, together with the dismantling of the power imbalance within the healthcare provider–PLHIV relationship and sexual health skills empowerment among providers, were used to develop a humanised and demedicalised National U=U Training Curriculum. IHRI, FAR and TNP+ co-developed and piloted the Curriculum and training tools.

The National U=U Training Curriculum contains the following key modules: (1) Fine: participants are asked to charge a fine to a PLHIV who had condomless sex, then were asked to play the role of a PLHIV and give a reason why a condom was not used; (2) HIV Journey: a brainstorming session is conducted to review the evolution of the HIV epidemic and treatment availability in Thailand, which affected how healthcare providers communicated with PLHIV about sex and relationships; (3) U=U facts and myths: a brief informative session is held followed by an extensive Q&A session to clear up myths and highlight outdated counselling messages; (4) U=U values: participants learn from quotes made by PLHIV and their partners about what HIV took from them and how U=U can unlock guilt and allow them to enjoy life; (5) Take a Condom Side: participants are asked to play the role of a PLHIV who, after learning about U=U, will make a decision about whether to use a condom for sex that night; participants then hear various reasons – including the aspects of sex, sexual pleasure, and relationship – from their fellow participants on why they decided to use or not to use a condom; (6) Countering Automatic Negative Thoughts: participants review the answers from the Fine module session, are asked if they would like to change their mind, and reflect on how a ‘fine’ represents immediate judgmental attitudes and discriminative actions toward PLHIV clients in a healthcare setting; (7) Power Dynamics: a role-playing session is undertaken to understand the reasons and impacts of power imbalance in the healthcare setting and to re-design how power can be balanced in a healthy way; and (8) Designing U=U Communication: participants are asked to design and role-play how they will communicate U=U to their clients and the public.

Three documentaries have been developed to communicate U=U clinical and social science facts with the audience.¹⁰ The first documentary targets the general public. The second one uses healthcare providers to communicate with their professional friends about implementing U=U in a real-life setting. The last one communicates to PLHIV and their partners on how U=U allows them to live self-determined lives.

On 1 December 2022, a national event ‘The Declaration of U=U: Equal healthcare system for all, people living with HIV equals everyone’ was held to demonstrate Thailand’s commitment to using U=U as a main strategy to end AIDS and ensure that PLHIV can live an equal life to everyone else. The event was attended by 150 representatives from 28 civil society, governmental, and private sectors and raised public awareness about how people-centred U=U messages to combat stigma and discrimination related to HIV and diversity can be used in healthcare, workplace, and educational settings. U=U values quotes from the Assistant to the Public Health Minister, TNP+ Chair, Senior Prosecutor, National Congress of the Thai Labour Chair, a University Instructor, and a leading infectious disease doctor were used to produce a series of poster roll-ups and e-posters for dissemination. In addition, two National Working Groups were established to progress the U=U implementation in Thailand. The National U=U Strategic Plan Working Group worked toward having the U=U strategic plan being endorsed though a national event, implemented, and monitored. The National U=U Training Curriculum and Guidelines Working Group ensured that the development and implementation of the curriculum and guidelines are based on the people-centred U=U values.

Conclusion

U=U can be successfully humanised and demedicalised for efficient communication and implementation. At an individual and relationship level, U=U can be used to delve into and address one’s stigmatising attitudes toward HIV and other personal attributes of a person living with or at risk of HIV, including those related to intimacy, sex, and sexual pleasure. At a community level, U=U can tackle stigma and discriminatory practices beyond the healthcare setting. At a policy level, national U=U endorsement can initiate and sustain tangible actions and interest across the country’s leadership groups toward the goal of ending AIDS.

Data availability

The data that support this study will be shared upon reasonable request to the corresponding author.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Declaration of funding

The financial contribution of UNAIDS towards this study is gratefully acknowledged. However, its content and ideas expressed therein do not necessarily reflect the views and opinions of UNAIDS or engage the responsibility of UNAIDS.